Primary Complaints 207

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Anatomic essentials
Traditionally, burns have been described as first, sec-
ond (partial thickness), or third degree ( Figure 16.1 ).
Superficial burns (formerly referred to as first-degree
burns) injure only the epidermis. Superficial burns do
not damage the dermalepidermal junction (basement
membrane), and thus spare deeper skin structures
responsible for re-epithelialization (i.e., epidermal
appendages, hair follicles, sweat and sebaceous glands).
Superficial burns can be painful, and are characterized
primarily by erythema and the lack of blisters. Skin peel-
ing may be seen as erythema fades. Superficial burns
heal without scar formation in 35 days and should not
be included in the total body surface area (TBSA) calcu-
lation for initial fluid resuscitation requirements.
Second-degree burns are now commonly referred
to as either superficial or deep partial-thickness burns.
Superficial partial-thickness burns extend through the epi-
dermis into the papillary dermis, injuring pain-sensitive
nerve endings. These burns have intact sensation and are
painful. Blisters or bullae are common; these burns usually
Scope of the problem
It is estimated that fire and burn injuries account for
over 1 million annual emergency department (ED) visits
in the United States. The majority of these injuries are
managed on an outpatient basis; however, nearly 60,000
patients are hospitalized in the United States each year.
Despite the advances made in health care over the past
20 years, the mortality rate from fire and burns in the
United States remains among the highest of all indus-
trialized nations. Even with smoke and carbon monox-
ide (CO) detectors in homes, fire and burns are the fifth
leading cause of death from unintentional injury in the
United States, and the third leading cause of injury-
related death in the home.
Residential fires are the leading cause of fire-related
death and account for approximately 75% of fire-related
injuries. Cooking is by far the leading cause of residential
fires, whereas smoking is the leading cause of residential
fire deaths, accounting for approximately 25% of fatalities.
The combination of careless smoking and alcohol abuse
accounts for nearly half of all fire-related deaths.
David A. Wald , DO
16 Burns
Figure 16.1
A. Anatomy of the skin. B. Partial-thickness burn. C. Full-thickness burn. Chris Gralapp.
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208 Primary Complaints
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nerve endings; however, surrounding areas may be pain-
ful. All but the smallest full-thickness burns are treated with
skin grafting to help limit the development of hypertrophic
scarring. Some references in the literature may describe
appear pink and moist, and blanch to touch because cap-
illary refill is preserved ( Figure 16.2 ). Because the deeper
rooted epidermal appendages are spared, superficial par-
tial-thickness burns typically heal within 23 weeks with
little or no scarring.
Deep partial-thickness burns extend through the epi-
dermis and damage both the papillary and reticular der-
mis. These injuries may or may not be painful and often
appear white, mottled pink or cherry red ( Figure 16.3 ).
Deep partial-thickness burns have impaired sensation
and do not blanch to touch. In the immediate post-burn
period, deep partial-thickness burns can be difficult to
distinguish from full-thickness injury. Because the epi-
dermal appendages located in the reticular dermis are
damaged, the skin has a limited ability to re-epithelial-
ize and often takes 3 or more weeks to heal. Burns of
this depth often result in hypertrophic scarring if left to
heal spontaneously. It is important to keep in mind that
without proper care, some deep partial-thickness burns
will progress to full-thickness burns in the first few days
post injury .
Full- thickness burns (formally referred to as third-degree
burns) involve all layers of the epidermis and dermis, and
may extend into subcutaneous structures. These burns usu-
ally appear white or charred ( Figure 16.4 ). Full-thickness
burns are usually insensate due to the destruction of the
Figure 16.2
A. Superficial partial-thickness scald burn of the arm.
B. Superficial partial-thickness scald burn of the upper chest.
Figure 16.3
Deep partial-thickness burn from contact with a hot radiator. The
central area of contact with the radiator is of deeper depth than the
periphery of the burn.
Figure 16.4
A. Full-thickness flame burn of the chest, neck and upper arm.
B. Full-thickness flame burn of the lower leg.
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Primary Complaints 209
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What were the circumstances surrounding the
injury?
Information regarding the circumstances surrounding the
injury should be obtained from the patient, family, wit-
nesses, or prehospital care providers. Was the injury caused
by hot tap water, grease, or another hot liquid? Was the
injury caused by flame or contact with a hot object? Were
chemicals or industrial solvents involved? Details regard-
ing the mechanism of injury may suggest the depth of burn
injury and alert physicians to potential associated injuries.
The patients condition at the scene and any treatment pro-
vided by bystanders or an outside referring hospital should
also be sought.
Was the patient confined in a burning environment,
or was there a history of an explosion?
Patients involved in a closed space fire or an explosion
are at risk for inhalation injury . In addition, a history of
an explosion places patients at risk for barotrauma and
blast-related injuries.
Did the patient sustain associated traumatic
injuries?
Associated trauma may be masked in a patient with a sig-
nificant burn injury. All burn patients should undergo a
systematic trauma assessment. If the patient was in a house
fire, it is important to find out how the patient got out of
fourth-degree burns which involve deeper structures (i.e.,
muscle and bone).
Red flags
Emergency clinicians must be adept at recognizing red
flags (warning signs and symptoms) from the history
and physical examination that raise concern for life-
threatening or dangerous diagnoses ( Table 16.1 ).
History
A focused history should be performed on all burn
patients. Key historical information may heighten the
suspicion for associated injuries and can influence
management.
When did the burn occur?
Determining the timing of a burn is important for patients
requiring IV fluid resuscitation. Delays in initiating fluid
resuscitation increase fluid requirements, and delays
greater than 2 hours after burn injury are associated with
increased mortality. Determining the time of injury is
important when evaluating acute or subacute burn inju-
ries, as the depth of certain deep burns will not be evident
in the immediate post-burn period.
Table 16.1 Burns red flags
History Concerning diagnosis
Burns in a confined space Inhalation injury
Explosion Barotrauma or other associated trauma
Difficulty speaking, swallowing or drooling Upper airway burns or inhalation injury
Coughing, wheezing or difficulty breathing Inhalation injury
Headache, dizziness, or history of loss of consciousness at the scene Carbon monoxide toxicity
Burn wound inconsistent with history Non-accidental trauma
Preexisting medical conditions (HIV/AIDS, renal disease, liver
disease, and metastatic cancer)
Increased morbidity, mortality and length of hospitalization
Examination finding Concerning diagnosis
Tachypnea Airway burn
Hypotension Volume depletion or other associated significant trauma
Burns to the face, neck or upper torso; singed eyebrows and nasal
vibrissae; carbon deposits and acute inflammatory changes in the
oropharynx; carbonaceous sputum
Airway burns or inhalation injury
Burns that are painful and characterized primarily by erythema and
lack of blisters
Superficial burns
Burns that are painful and usually appear pink, moist, with blisters
or bullae
Superficial partial-thickness burns
Burns that appear white, mottled pink or cherry red with impaired
sensation
Deep partial-thickness burns
Burns that appear white or charred with impaired sensation Full-thickness burns
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210 Primary Complaints
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Neurologic
Ask about headache, dizziness, or a history of loss of con-
sciousness at the scene? In the context of a burn injury or
fire exposure, these symptoms suggest concomitant CO
toxicity. Complaints of CO toxicity are often subtle, so a
high index of suspicion must be maintained.
Past medical
After controlling for patient age, sex, TBSA burned and
the presence of inhalation injury, several preexisting medi-
cal conditions are associated with increased mortality risk
and length of hospital stay in patients with an acute burn
injury. Preexisting medical conditions with the highest
mortality risk include HIV/AIDS, renal disease, liver dis-
ease and metastatic cancer. Other conditions independ-
ently associated with an increased mortality risk in the
burn patient are pulmonary circulation disorders, con-
gestive heart failure, obesity, non-metastatic malignan-
cies, alcohol abuse, peripheral vascular disorders, cardiac
dysrhythmias and patients with neurologic disorders.
Several conditions are associated with prolonged hospital
stays but no increase in mortality. These include paraly-
sis, dementia, peptic ulcer disease, psychiatric illness,
cerebrovascular disease, valvular disease, diabetes, drug
abuse and hypertension. The presence of one or more
preexisting comorbidities may warrant hospital admis-
sion or transfer to a regional burn center for patients with
otherwise minor or moderate size burns.
Physical examination
When evaluating a burn patient, the physical examina-
tion should be performed in a systematic fashion (as
for all trauma victims). After life-threatening conditions
are identified and addressed, the emergency physician
should determine the depth and TBSA of the burn.
Vital signs
Major burns lead to a hyperdynamic state commonly
associated with tachycardia. For this reason, the heart
rate should not be used in isolation as a reliable indicator
of volume status. Tachypnea may also indicate a hyper-
dynamic state or airway involvement. If hypotension
is present, volume depletion resulting from third spac-
ing of fluids or associated trauma should be given high
priority.
Primary and secondary surveys
The physical examination begins with the primary sur-
vey. Immediate life-threats should be addressed first,
which may be difficult given the dramatic nature and
overpowering odor of burns. Additional attention should
be given to clinical findings associated with inhalation
injury, such as burns to the face, neck or upper torso;
singed eyebrows and nasal vibrissae; carbon deposits
the building (i.e., did they jump out of a window or were
they found in bed). Burns associated with motor vehicle
collisions are often associated with traumatic injuries.
Is the burn painful?
Typically, all superficial partial thickness burns are pain-
ful. Deeper burns, such as deep partial-thickness and
full-thickness burns, are often less painful or painless,
respectively.
Were there suspicious circumstances surrounding
the burn injury?
It is important to consider that burn injuries might be
self-inflicted, perhaps in a suicide attempt or gesture.
Additionally, toxic ingestions or potentially lethal over-
doses can occur prior to setting oneself or a building
on fire.
Is the burn pattern consistent with the explanation?
Burns with a clear line of demarcation, or located on the
buttocks, between the childs legs or other areas that
would be difficult for the child to reach should be very
concerning for burns inflicted by another individual
(abuse). Concurrent injuries or bruises at different stages
of healing are also suspicious for child abuse, which is far
more common than most physicians believe. Additional
information suggestive of non-accidental burn injury
includes delays in seeking care, a pattern of burn injury
inconsistent with the childs motor abilities, or witness
stories that do not correlate or seem possible. Abuse
should be considered when caregivers appear angry,
resentful toward the child, or even overly protective or
afraid of letting their child speak to physicians alone. In
other words, the possibility of abuse should be considered
in all traumatic injuries in children, especially burns.
Associated symptoms
Head, eyes, ears, nose and throat (HEENT)
Ask about difficulty speaking or swallowing? Difficulty
speaking or swallowing, or pain during these activi-
ties suggests an upper airway burn or inhalation injury,
which may portend future airway compromise. Any
voice change (including hoarseness) may indicate injury
to or edema of the larynx and vocal cords.
Ask about difficulty with vision, such as blurred vision,
photophobia, or pain? Visual complaints suggest ocular
involvement, including burns, abrasions, or edema of
the cornea. Foreign bodies (including penetration of the
globe or orbit from flying debris) may accompany some
burn injuries or explosions.
Pulmonary
Ask about coughing, wheezing, or trouble breathing?
These respiratory complaints suggest the possibility of
lung inhalation injury .
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Primary Complaints 211
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However, distinguishing between superficial partial-
thickness and all deeper burns may help reduce hospi-
tal transfers of some patients with minor burns. Bedside
testing may help emergency physicians differentiate
between burns of different depth, specifically between
superficial partial-thickness and all deeper burns . A clini-
cal approach to evaluating burn depth at the bedside is
provided ( Table 16.2 ).
In adults, the TBSA estimation of the burn is commonly
based on the rule of nines ( Figure 16.5 ). Although ade-
quate for adults, application of this rule can lead to inac-
curate burn size estimations in infants and small children,
who have larger surface body area-to-weight ratios than
older children, adolescents, or adults . A more accurate
estimation of TBSA burned can be obtained using the
Berkow or Lund-Browder burn size chart ( Figure 16.6 ) .
These formulas estimate burn size based on age and
and acute inflammatory changes in the oropharynx; and
carbonaceous sputum. In addition, any change in voice
quality, stridorous respirations, wheezing, hoarseness,
or drooling should alert physicians to the probability of
airway involvement . While performing the secondary
survey, emergency physicians should closely examine
the entire patient to determine the depth and TBSA of
the burn, in addition to identifying associated traumatic
injuries.
Determination of burn depth
and TBSA burned
Burn depth and TBSA determination will guide initial
fluid resuscitation volume and the need for hospitaliza-
tion or transfer to a regional burn center. In addition, burn
wound classification includes identification of preexisting
medical conditions, associated trauma, inhalation injury,
and unusual circumstances such as consequences or loca-
tion of the burn. For the purpose of fluid resuscitation,
no distinction is made between partial-thickness and full-
thickness burns.
Even experienced clinicians and burn specialists are not
always able to differentiate between deep partial-thickness
and full-thickness burns at the time of injury. First of all,
many burns are not uniform in depth. Furthermore, burns
of similar depth may not look alike due to differences in
underlying skin pigmentation. When evaluating the depth
of a burn, the age of the patient also needs to be considered,
as children less than 2 years of age and the elderly have
thin skin (dermis). As a result, patients at the extremes of
age may have full-thickness injury following an exposure
(e.g., hot tap water) that might only cause a partial-thick-
ness injury in an older child, adolescent or adult.
Traditionally, burn wound classification has empha-
sized the distinction between partial- and full-thickness
injury (previously referred to as second- and third-degree
burns). In the immediate post-burn period, it may be more
clinically relevant to distinguish between superficial par-
tial thickness and all deeper (deep partial-thickness and
full-thickness) burns. For patients with moderate to major
burns, this distinction does not affect initial fluid resus-
citation requirements or the need for hospitalization.
Table 16.2 A bedside assessment of burn depth
Superficial burn
Superficial
partial-thickness burn Deep partial-thickness burn Full-thickness burn
Bleeding on pin prick
testing
Brisk Brisk Delayed None
Sensation Painful Painful Dull None
Appearance Light red, dry Moist, pink Mottled pink-red or waxy
white
White, charred, dry
Blanching to pressure
(capillary refill)
Brisk Slow return None None
Testing for bleeding and sensation can be performed with a 21-gauge needle. Testing for blanching can be performed with a sterile
cotton tip swab.
Adapted from Hettiaratchy S, Papini R. Initial management of a major burn: I Overview. BMJ 2004;328(7455):15557.
Head and
neck 9%
Trunk
Front 18%
Back 18%
Arm 9%
(each)
Genital
area 1%
Leg 18%
(each)
Figure 16.5
Rule of nines.
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212 Primary Complaints
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small to moderate burns may result in unnecessary hos-
pital transfers.
Differential diagnosis
A number of dermatologic conditions may present
with skin findings that appear similar to a burn wound
( Table 16.3 ). Some of these conditions are cared for in
burn centers, because treatment of skin manifestations,
patient handling and associated complications are similar
to those of burn victims.
body location, and take into account the different ratios
of the head and lower extremities in childhood compared
with adulthood . The size of small burns can also be esti-
mated using the rule of palms , which assumes that a burn
the size of the patients palm accounts for roughly 1% of
their TBSA. With children, the entire volar surface of the
hand more closely approximates 1% TBSA than the palm
itself.
Inaccurate assessment of burn depth and size can
adversely impact the calculation of the initial fluid resus-
citation volume. This can lead to over-resuscitation of
small to moderate size burns, and under-resuscitation
of larger burns. In addition, overestimation of the size of
A
% Total Body Surface Area Burn
Be clear and accurate, and do not include erythema
(Lund and Browder)
1
13
2
1
1
/
2
1
1
/
2
1
1
/
2
1
1
/
2
1
3
/
4
1
3
/
4
2
1
B
C
B
C
A
1
13
2
1
1
/
2
2
1
/
2
2
1
/
2
1
1
/
2
1
1
/
2
1
1
/
2
1
3
/
4
1
3
/
4
2
B
C
B
C
REGION FTL PTL
%
Head
Neck
Ant. trunk
Post. trunk
Right arm
Left arm
Buttocks
Genitalia
Right leg
Left leg
Total burn
AREA Age 0 1 5 10 Adult 15
A =
1
/
2
OF HEAD
B =
1
/
2
OF ONE THIGH
C =
1
/
2
OF ONE LOWER LEG
9
1
/
2
2
3
/
4
2
1
/
2
8
1
/
2
3
1
/
4
2
1
/
2
4
1
/
2
4
1
/
2
3
1
/
4
3
1
/
2
4
3
/
4
3
1
/
2
5
1
/
2
4
1
/
2
3
6
1
/
2
4
2
3
/
4
Figure 16. 6
Burn size estimation based on age and body location.
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sium, myoglobin, and creatine phosphokinase should be
obtained, especially in large TBSA burns.
Electrocardiogram (ECG)
Cardiac monitoring should be initiated and a baseline
ECG should be obtained in a patient with a history of
high-voltage electrical injury, those with known heart dis-
ease or at risk for cardiac complications, and all patients
admitted to an intensive care unit. Adult patients trans-
ferred to a burn center should have an ECG reviewed
prior to transfer.
Radiologic studies
Imaging studies should be obtained as clinically indi-
cated. Although commonly obtained, chest radiography
is not sensitive in detecting inhalation injury, and should
not be relied on to determine its presence or guide initial
therapy.
Laryngoscopy
In cases of suspected inhalation injury or burns of the
airway, the upper airway should be visualized by direct,
nasopharyngeal, or fiberoptic laryngoscopy. Additionally,
the tracheobronchial tree can be visualized by fiberoptic
bronchoscopy, if necessary.
General treatment principles
Prehospital care
Burn management should begin at the scene. Prehospital
care providers should carefully remove the patient from
the site of injury and perform a primary and focused
secondary survey to address life-threatening conditions.
Diagnostic testing
Diagnostic testing should be used selectively in patients
with burns. Cases must be handled on an individual
basis, as many minor or moderate burn patients require
limited or no diagnostic testing. Routine laboratory stud-
ies, such as complete blood count (CBC), basic metabolic
profile, and coagulation studies are typically obtained for
all burn patients requiring hospital admission or transfer
to a regional burn center. Additional laboratory studies
may be indicated.
Laboratory studies
Arterial blood gas analysis
Arterial blood gas analysis is typically indicated in
patients with suspected inhalation injury or those
requiring intubation and mechanical ventilation.
Carboxyhemoglobin (COHb) levels help guide therapy
in cases of suspected or positive CO toxicity. A venous
blood gas sample can determine the COHb level .
Type and screen
Type and screening of blood is recommended in patients
requiring burn unit admission, as well as other patients
who may require blood products or need an operative
intervention.
Toxicology testing
Serum ethanol level or urine toxicology screening may be
indicated in certain situations.
Miscellaneous
As clinically indicated, additional laboratory studies
such as hepatic function, calcium, phosphorous, magne-
Table 16.3 Dermatologic conditions that appear similar to burns
Diagnosis Symptoms Signs Workup
Pemphigus vulgaris Mucous membrane lesions are
typical and often precede
other skins lesions by
months
Mucosal erosions in the mouth are
common
Fluid-filled blisters / bullae can be seen
Positive Nikolskys sign
Diagnosis confirmed by
histopathology or direct
immunofluorescence
Staphylococcal
scalded skin
syndrome
Usually begins with fever and
generalized erythematous
rash
Rash progresses from maculopapular
scarlatiniform to desquamating bullous
Positive Nikolskys sign
Diagnosis confirmed by
culture and biopsy
Stevens-Johnson
syndrome
Typical nonspecific prodrome Fever is common
Skin rash can be maculopapular or
vesicular
Erythema and bullae can develop
Ruptured bullae / skin sloughing leave
the patient susceptible to secondary
infection
Diagnosis confirmed by
biopsy
Toxic epidermal
necrolysis
Prodrome typical of fever,
cough, sore throat and
malaise
Erythematous rash with a purpuric center
Lesions coalesce forming bullae
Skin sloughing at dermal-epidermal
junction
Positive Nikolskys sign
Diagnosis confirmed by
biopsy
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214 Primary Complaints
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Prehospital care providers should determine the need
for any immediate interventions, such as airway control,
breathing or circulatory support, and cervical spine immo-
bilization. Large burns should be covered with dry sterile
dressings; small or moderate size burns can be covered
with cool wet dressings to help relieve pain. Supplemental
oxygen should be administered if smoke inhalation is sus-
pected. Intravenous fluid administration should be initi-
ated, preferably at a site that does not involve the burn .
Intravenous narcotics should be administered (according
to protocol) . Whenever possible, individuals with exten-
sive burns should be transported directly to a trauma or
regional burn center.
Emergency department care
The resuscitation area should be prepared with dry sterile
sheets, appropriate protective covering for medical per-
sonnel, and airway equipment for the anticipated arrival
of a major burn victim. The ED evaluation should be sys-
tematic and be performed as any other trauma scenario,
starting with the ABCs (airway, breathing, circulation).
The airway is the most important initial consideration in
the severely burned patient. Assessment for possible air-
way involvement in a patient with suspected inhalation
injury is vital. After the primary survey and treatment
of any immediate life-threats, the emergency physician
should perform a detailed traumaburn secondary sur-
vey. This specifically focuses on evaluating for possible
smoke inhalation and identifying associated traumatic
injuries, followed by an estimation of burn depth and
size. This critical step will determine the initial fluid
resuscitation volume and influence patient disposition. In
the patient requiring transfer to a regional burn referral
center, early communication with the burn specialist is
recommended.
Inhalation injury
Inhalation injury has been reported in 7% of cases reported
to the National Burn Registry, and in approximately one-
quarter of patients with burns 20% TBSA. The incidence
of inhalation injury increases with larger burns, presenting
in approximately two-thirds of patients with TBSA burns
that exceed 70%. Smoke inhalation accounts for >50% of
fire-related deaths; when present, it increases the morbid-
ity and mortality associated with all burn injuries. It also
increases the initial fluid resuscitation requirements after
thermal injury.
Smoke inhalation can cause both airway injury and
systemic toxicity. Injury to the upper airway structures
(lips to glottis) occurs from inhalation of superheated
gases from flame, smoke, or steam. Thermal injury to
the lower airway (subglottic structures) is rare because
of reflex closure of the glottis and heat dissipation that
occurs throughout the tracheobronchial tree. An excep-
tion is inhalation injury resulting from steam, because of
its ability to carry approximately 4,000 times as much heat
as dry air.
Injury to the lower airway usually occurs as a result
of inhalation of toxic gases and particulate matter. This
Figure 16.7
Flash burns to the face represent a high risk for an inhalation injury.
can lead to airflow obstruction from the production of
mucosal edema, intraluminal debris, inspissated secre-
tions and bronchospasm, subsequently resulting in a
chemical tracheobronchitis. If severe, the clinical picture
can resemble adult respiratory distress syndrome (ARDS)
and further manifest with decreasing pulmonary compli-
ance, increasing airway resistance, hypoxemia and hyper-
carbia.
Patients suffering from smoke inhalation may also
exhibit toxicity from systemic absorption of products
of combustion, possibly leading to CO or cyanide tox-
icity. On arrival, all spontaneously breathing patients
with suspected smoke inhalation should immediately
be placed on high-flow humidified oxygen. Early intu-
bation should be considered if airway compromise is
supported by history and bedside examination. It is
crucial to identify which patients with smoke inhalation
require early endotracheal intubation. The presence of
classic indicators of smoke inhalation (i.e., facial burns,
carbonaceous sputum, wheezing, voice change) does not
necessarily mandate emergent endotracheal intubation
( Figure 16.7 ). Unfortunately, no group of signs or symp-
toms can substitute for sound bedside clinical judgment.
Furthermore, intubation may become more difficult as
edema of the upper airway increases with time. When
emergent intubation is not necessary, close observation
with frequent serial examinations must be performed,
and airway equipment (including equipment for man-
aging the difficult airway) must be available at the
bedside.
Carbon monoxide toxicity
CO has an affinity for hemoglobin (Hb) approximately
230 times that of oxygen. COHb decreases the amount
of hemoglobin available for oxygen binding and reduces
the oxygen-carrying capacity of the blood, leading to
impaired tissue oxygenation.
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Primary Complaints 215
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resuscitation. However, in patients with severe burns
(>40% TBSA), central venous access using the internal
jugular or subclavian vein is the preferred route for fluid
resuscitation.
Lactated Ringers solution is most frequently used for
fluid resuscitation of burn patients. In comparison with
normal saline solution, which contains sodium 154 mEq/L
and chloride 154 mEq/L, Lactated Ringers solution con-
tains sodium 130 mEq/L, chloride 109 mEq/L, calcium
3 mEq/L, potassium 4 mEq/L and lactate 28 mEq/L.
In addition, Lactated Ringers solution has a higher pH
compared with normal saline and more closely resembles
physiologic pH (6.5 vs. 5.0, respectively).
The Parkland formula is most commonly used to
guide initial fluid resuscitation during the first 24 hours
after burn injury. This formula has gained almost uni-
versal acceptance, not necessarily for its demonstrated
superiority, but more likely because it is easy to remem-
ber and use. The Parkland formula calls for the admin-
istration of 4 mL/kg of body weight per %TBSA burn
(partial- or full-thickness) of intravenous crystalloid
fluid over the first 24 hours. Half of the calculated
fluid requirement should be administered over the first
8 hours post burn, and the remaining volume over the
next 16 hours. Front loading the burn resuscitation flu-
ids over the first 8 hours is required because the early
post-burn period is highlighted by increased capillary
permeability, protein leak, edema formation and loss of
plasma volume.
No resuscitation formulas can accurately predict vol-
ume requirements for an individual patient. Therefore,
continuous monitoring and reassessment of resuscitation
targets such as blood pressure, mental status and urine
output is necessary. In adults, a common goal is urine out-
put of at least 0.5 to 1 mL/kg/hr, a reasonable indicator of
renal perfusion. However, urine output can be affected by
the use of diuretics or the presence of glycosuria (result-
ing in an osmotic diuresis). Greater urine output may
be needed in the presence of rhabdomyolysis to prevent
pigment-induced nephropathy. A bladder catheter and
urometer should be used to monitor urine output in all
critically ill patients.
Escharotomy
An escharotomy may be indicated to relieve restricted ven-
tilation (from circumferential thorax burns) or impaired
extremity circulation (from eschar formation in circum-
ferential deep partial-thickness or full-thickness extrem-
ity burns). In either of these cases, the eschar should be
incised through the dermis down to the level of the sub-
cutaneous fat. If a chest wall escharotomy is required, a
vertical incision should be made from the clavicles to the
costal margin along the anterior axillary line. This inci-
sion may be joined by a transverse incision along the
superior, anterior abdominal wall. If a neck escharotomy
is required, incisions should be made posterolaterally to
avoid vascular structures. On the extremities, incisions
are made on the medial and lateral surfaces, with special
attention when crossing joints to avoid injuring neuro-
vascular structures.
Pulse oximetry is a noninvasive tool that measures
functional oxygen saturation. The pulse oximeter can-
not distinguish between COHb and oxyhemoglobin, and
the presence of COHb produces falsely elevated oxygen
saturation readings. This overestimation of oxygen satu-
ration (known as the pulse oximetry gap) approaches
the measured COHb level.
Alternatively, a co-oximeter is a device that analyzes
a small blood sample to measure concentrations of
oxyhemoglobin, deoxyhemoglobin, COHb, and meth-
emoglobin. Therefore, it can confirm CO toxicity by iden-
tifying elevated COHb levels. Traditionally, an arterial
blood sample has been used to determine the COHb level;
however, a venous blood sample provides a reliable, often
less painful alternative. The Masimo Rainbow SET Pulse
CO-Oximeter is now available as a noninvasive alterna-
tive to screen for CO toxicity.
All patients with known or suspected CO toxicity
should receive high-flow oxygen. This can reduce the
elimination half-life of COHb (COHb T

) from 240
320 minutes at room air to 6090 minutes. The COHb
T

of patients treated with high-flow oxygen by face

mask or 100% oxygen if intubated does not appear to
be influenced by patient age, gender, history of loss of
consciousness, concurrent tobacco use, or initial COHb
level.
Hyperbaric oxygen (HBO) therapy has been shown to
further reduce the COHb T

to approximately 23 minutes
(at three atmospheres with 100% oxygen). Specific selec-
tion criteria can identify candidates appropriate for HBO
therapy. Patients with myocardial ischemia, cardiac dys-
rhythmias, neuropsychiatric abnormalities, syncope or
persistent neurologic findings in the face of CO toxicity
should be considered for HBO therapy. All patients with
COHb levels >25% , and pregnant women and young
children with levels 15% are also candidates for HBO
therapy.
It is also important to recognize that patients with
similar COHb levels may exhibit varying systemic toxic-
ity. Cyanide toxicity can also complicate severe cases of
CO toxicity and should be considered in victims of smoke
inhalation with persistent hypotension and acidemia
despite adequate arterial oxygenation.
Fluid resuscitation
Fluid resuscitation in the early post-burn period is cru-
cial and should be the top management priority once
the airway and other life-threats have been addressed.
Over the past 50 years, aggressive volume replacement
in the hours immediately following a severe burn has
decreased the morbidity and mortality associated with
these injuries. The goal of initial fluid resuscitation is to
restore and maintain vital organ perfusion and prevent
burn shock.
Intravenous fluid resuscitation should be initiated in
adults with partial- or full-thickness TBSA burns >20%,
in older children with burns 15% TBSA, and in infants
with burns 10% TBSA. Peripheral intravenous access
is sufficient for the majority of patients requiring fluid
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216 Primary Complaints
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outpatient setting, topical antimicrobial agents are most
effective for small- to moderate-sized superficial partial-
thickness burns that are expected to heal within 23 weeks.
When applied to deeper burns, topical antimicrobials can
prevent wound infections in anticipation of a skin graft.
Unfortunately, no consensus opinion or high-quality
research presently exists to support one antimicrobial
Outpatient care of burns
Proper patient selection is necessary to ensure optimal
burn care in an outpatient setting. The American Burn
Association (ABA) has proposed a grading system for esti-
mating burn severity and disposition ( Table 16.4 ). Under
ideal conditions, adults with superficial partial-thickness
burns <10% TBSA and children with TSBA burns <5% may
be considered candidates for outpatient management, as
these burns fall into the minor category according to
the ABA grading system.
The wound care principles for minor burns are the
same as for other minor wounds. Minor burns should be
cleansed with gentle soap and water, and hair around the
burn should not be shaved. Devitalized skin or ruptured
blisters should be debrided using aseptic technique. In
general, blisters should be left intact. Large or tense blis-
ters can be decompressed by needle aspiration. Tetanus
status should be updated according to current Centers for
Disease Control and Prevention (CDC) guidelines.
Most burns managed in the outpatient setting are
covered with closed dressings. The first layer should be
non-adherent, porous, dry sterile gauze. This is covered
with a layer of bulky gauze to absorb wound exudate, and
subsequently covered with a semi-elastic wrap. Silver sul-
fadiazine cream (Silvadene) is commonly used for super-
ficial partial-thickness burns. A thin layer of Silvadene can
be applied to non-adherent, porous sterile gauze using a
tongue blade. The gauze is then applied directly to the
burn ( Figure 16.8 ). In general, these dressings are changed
once or twice daily, and can be removed in the shower
or under running water. The burn is gently washed with
mild soap and water and the old cream removed. The
wound is then patted dry and re-dressed as above.
Topical antibiotic ointments (Bacitracin, Polymyxin
B sulfate, Neomycin, Polysporin, Neosporin) may be
applied to partial-thickness burns when Silvadene is con-
traindicated, such as in patients allergic to sulfonamides,
pregnant women approaching or at term, newborn infants
during the first 2 months of life, or patients with glucose-
6-phosphate dehydrogenase (G6PD) deficiency. In the
Table 16.4 American Burn Association grading system for burn severity and disposition
Minor burn Moderate burn Major burn
Criteria <10% TBSA in adult 1020% TBSA in adult >20% TBSA in adult
<5% TBSA in young (<10 years) or
old (>50 years)
510% TBSA in young or old >10% TBSA in young or old
<2% full-thickness burn 25% full-thickness burn >5% full-thickness burn
High-voltage injury High-voltage burn
Suspected inhalation injury Known inhalation injury
Circumferential burn
Concomitant medical problem
predisposing to infection (e.g.,
diabetes, sickle cell disease)
Any significant burn to face, eyes,
ears, genitalia, hands, feet, or
major joints
Significant associated injuries (e.g.,
major trauma)
Disposition Outpatient management Hospital admission Referral to burn center
From American Burn Association. Hospital and Prehospital Resources for Optimal Care of Patients with Burn Injury: Guidelines for
Development and Operation of Burn Centers. J Burn Care Rehabil 1990;11:98104.
Figure 16.8
A. Application of a thin layer of Silvadene to sterile gauze.
B. Silvadene- covered sterile gauze is applied to a burn wound.
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Primary Complaints 217
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(mean 4%); however, they can be associated with signifi-
cant morbidity, as they often occur in critical areas such as
the face, hands and feet. Occupational injuries that occur
during roofing and road paving account for the majority
of tar burns.
Used commonly as a protective coating, roofing tar
is generally heated to higher temperatures (232C) than
road paving tar (140C) to achieve the desired viscosity.
As a result, roofing tar burns tend to injure deeper ana-
tomic structures. When tar splatters, it cools to a tempera-
ture of 93104C, forming a hard, water-resistant residue.
Removing adherent tar without causing further damage
to the underlying skin is challenging. A number of non-
toxic preparations are efficacious for removing adherent
tar, including Neosporin, Tween 80, moist exposed burn
ointment (MEBO), De-Solv-it, NISA baby oil, butter, may-
onnaise and sunflower oil.
Scald burns
Scald burns from hot liquid or steam account for more
than half of all burn-related hospitalizations in the United
States. Scald burns are the most common type of injury in
children less than 3 years of age, accounting for approxi-
mately 70% of all pediatric burns requiring hospitaliza-
tion. In the elderly (age >65 years), non-fatal scald burns
from hot food most commonly affect the arm and hand.
Scald burns typically occur in the home, specifically the
kitchen. In addition, scald burns are a common occupa-
tional injury in restaurant workers. Preventive measures
include avoiding mixing water with hot oil when frying,
turning pot handles away from the stoves edge, and
using dry oven mitts or pot holders.
Despite being somewhat under-recognized, hot tap
water is a preventable cause of scald burns ( Figure 16.9 ).
Patients at greatest risk for tap water scald burns include
the elderly, children <5 years of age, and those with disa-
bilities. Scald burns from hot tap water are directly related
to the duration of exposure. Many home water heaters are
set at between 60C and 70C (140F and 158F). Exposure
at these temperatures can cause full-thickness burns in
less than 5 seconds. Lowering the temperature of a home
water heater to 49C (120F) would drastically reduce the
number and severity of burns from hot tap water. At this
temperature, it would take between 5 and 9 minutes to
cause a full-thickness injury.
Chemical burns
Chemical burns can be especially challenging to treat.
Initial treatment at the scene consists of copious irrigation
with water and removal of any particles. Burns due to ele-
mental chemicals (e.g., lithium, sodium, magnesium and
potassium) are important exceptions to irrigation with
water because the resulting exothermic reaction increases
the amount of burn.
Burns caused by hydrofluoric acid (a strong inorganic
acid commonly found in rust removers, etching solu-
tions, metal cleaners and electronics manufacturing) are
extremely painful due to the corrosive effect of the hydrogen
agent over another. Topical neomycin or neomycin-
containing agents (e.g., Neosporin) may cause an allergic
dermatitis and should be avoided whenever possible . In
recent years, newer long-acting silver impregnated and
other synthetic dressings have become available.
Select outpatient burns can be managed in an open
fashion without occlusive dressings. Wounds most com-
monly treated in this fashion are superficial partial-
thickness burns on the neck and face. These burns should
be gently washed twice daily with soap and water, fol-
lowed by application of a topical antibiotic ointment, and
then left open to air. Silvadene can cause permanent silver
staining of the skin and should not be used on the face.
Patients should be instructed to avoid sun exposure
during wound maturation, as this may lead to permanent
hyperpigmentation of newly re-epithelialized skin. After
re-epithelialization occurs, an unscented moisturizing
cream (such as Vaseline Intensive Care, Eucerin, or cocoa
butter) should be applied to the wound until the natural
lubricating mechanisms of the skin return.
Patients managed in the outpatient setting should first
be reevaluated in 2448 hours, and then every few days
until the burn wounds have healed. Minor burns initially
managed as an outpatient should be promptly referred to
a burn specialist if re-epithelialization has not occurred
within 23 weeks or if any complications occur.
Analgesia
The majority of burns are painful. Most outpatients can
be managed with nonsteroidal antiinflammatory medica-
tion with or without the addition of oral narcotic agents.
Patients admitted to the hospital often require intravenous
narcotic agents. Intramuscular (IM) analgesics should be
administered with caution (if at all) in burn victims, as
absorption is less reliable and titration is more difficult.
Antibiotics
Routine use of systemic antibiotics is not recommended
for patients with acute burn injuries.
Nasogastric tube
Patients with burns 20% TBSA may develop a paralytic
ileus; a nasogastric tube may prevent gastric distention
and emesis.
Bladder catheterization
In critically ill patients, bladder catheterization and urom-
eter placement is recommended to monitor urine output.
Special burns
Tar burns
Hot tar burns, while uncommon, remain a distinct and
problematic injury. Tar burns typically affect a small TBSA
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218 Primary Complaints
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deaths. Children 4 years of age or younger are at the great-
est risk of burn-related injury, accounting for nearly twice
the number of burn-related victims as all other pediatric
age groups combined. Despite various prevention strate-
gies initiated over the past two decades, burns remain the
fourth leading cause of unintentional injury-related death
in children between 1 and 14 years of age.
Young children have an increased body surface area-
to-weight ratio compared with adults, and therefore have
greater fluid requirements than estimated by standard
weight-based resuscitation formulas. Failure to include
maintenance fluids when resuscitating a young child with
a moderate or major burn can result in significant under-
resuscitation and vital organ hypoperfusion. Maintenance
fluids may be administered as 5% dextrose in normal
saline. Daily maintenance fluids are based on the childs
weight: 100 mL/kg for the first 10 kg, then 50 mL/kg up
to 20 kg, then 20 mL/kg > 20 kg.
It is also important to closely monitor blood glucose
levels and temperatures in young children, particularly
those who weigh <20 kg. Because of limited hepatic glyco-
gen stores, small children have increased susceptibility to
hypoglycemia; adding 5% dextrose to Lactated Ringers
solution can prevent hypoglycemia in young children.
Small children are also at risk for hypothermia from large
burns, as they have smaller muscle mass (limiting their
heat generation from shivering) and increased insensible
fluid losses (reducing their capacity for adequate thermo-
regulation).
It is estimated that approximately 10% of pediatric
burns are non-accidental, the peak incidence occurring
between 13 and 24 months of age. Non-accidental burns
should be suspected with any of the following injury
patterns: inconsistent history, suspicious-appearing inju-
ries, delay in seeking medical care, stocking or glove
burns (suggesting immersion injury), or a doughnut pat-
tern burn (central sparing) on the buttocks .
Elderly
Elderly patients are at increased risk of burn wounds,
with greater complications from burns of similar depth
and surface area. Elderly patients typically have thinner
skin, multiple comorbidities, less ability to avoid burns,
and more physical and psychosocial needs. Elderly
patients are also more likely to require a tetanus immu-
nization update.
Disposition
The overwhelming majority of patients with burn inju-
ries who seek emergency medical treatment will be
amenable to outpatient treatment. However, approxi-
mately 5% of patients with burns will require hospi-
talization, many requiring transfer to a regional burn
center. Other factors to consider when determining suit-
ability for outpatient care include the patients general
state of health, need for ongoing parenteral analgesia,
social and family support, ability to follow instructions
ions and penetrating effect of the fluoride ions. Skin injury
may appear mild yet cause severe pain. Copious irriga-
tion followed by topical application of calcium gluconate
gel may control pain. The gel can be applied using a latex
glove if the fingers or hands are burned. If this measure
plus narcotics does not control the pain, regional or intra-
arterial infiltration of calcium gluconate may be necessary.
Life-threatening hypocalcemia and its associated compli-
cations have been reported from hydrofluoric acid burns.
Electrical burns
Electrical injuries include those due to high voltage
(>1,000 volts), low voltage (<1,000 volts), lightning
strikes and arc flash burns. Although these injuries
represent a small percentage of burn unit admissions, they
are associated with significant morbidity and mortality.
High-voltage injuries (typically males, mean age 35 years)
most commonly result from contact with power lines.
Electrical arc injuries have the lowest morbidity (approxi-
mately 1%) but are associated with the largest TBSA. Low-
voltage injuries often occur in younger patients (mean
age 23 years), and are most likely to involve burns of the
upper extremity. Lightning injuries represent the smallest
subgroup (approximately 2% of burn unit admissions) but
have the highest mortality (17%). In general, survivors of
high-voltage electrical injury have the greatest potential
for debilitating complications, including traumatic ortho-
pedic injury, fasciotomy and extremity amputation.
Hospital admission with cardiac monitoring is rec-
ommended for any electrical injury patient with loss of
consciousness, an abnormal initial ECG, or an associated
condition necessitating admission. The majority of adult
patients sustaining low-voltage electrical injury who have
a normal initial ECG can be discharged from the ED.
Special patients
Pediatrics
Children are a challenging subgroup of burn victims
and comprise one-third of all burn unit admissions and
Figure 16.9
Bilateral lower-extremity scald burns from bath water.
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References
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2. Ayers DE , Kay AR . Management of burns in the
wilderness . Travel Med Infect Dis 2005 ; 3 (4):
239 48.
3. Baruchin AM , Schraf S , Rosenberg L . Hot
bitumen burns: 92 hospitalized patients . Burns
1997 ; 23 (5): 438 41.
4. Burn injuries in child abuse . US Department of Justice,
Office of Justice Programs, Washington, DC, 2001 .
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Assessment, triage, and early management of burns
in children . Clin Pediatr Emerg Med 2006 ; 7 (2): 82 93.
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wounds in the emergency department . Emerg Med
Clin North Am 2007 ; 25 (1): 135 46.
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major burn: I Overview . BMJ 2004 ; 328 (7455):
1555 7.
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Med Assoc J 1997 ; 156 (6): 841 4.
11. Moss LS . Outpatient management of the burn patient .
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2011).
and perform dressing changes, and access to follow-up
health care.
Several questions should be asked when considering a
patient for outpatient care:
1. Does the patient have an adequate home
environment suitable for outpatient care?
2. Is the patient capable of caring for the burn at home?
3. Are friends or family members available to assist
with burn care or activities of daily living?
4. Does the patient have the financial means to be cared
for as an outpatient?
5. Is the patient able to follow up as instructed,
including transportation to and from follow-up
appointments?
6. Do any psychosocial factors exist that may decrease
suitability for outpatient burn care?
Pearls, pitfalls and myths
Residential fires are the leading cause of fire-related
deaths, accounting for approximately 75% of fire-
related injuries.
Patients involved in a closed-space fire or explosion
are at risk of inhalation injury.
Complaints of headache or dizziness in the context of
a fire or burn injury suggest concomitant CO toxicity.
Even experienced clinicians are not always able to
accurately determine the depth of the burn, including
differentiating between a deep partial-thickness and
full-thickness burn at the time of injury.
Intravenous fluid resuscitation should be initiated
in adults with partial- or full-thickness TBSA burns
>20%, in older children with burns 15% TBSA, and
in infants with burns 10% TBSA.
Lactated Ringers solution is the most commonly
used fluid for burn resuscitation.
The Parkland formula calls for the administration of
4 mL/kg of body weight per %TBSA burn (partial- or
full-thickness burns) of intravenous fluid over the
first 24 hours (half over the initial 8 hours and the
remainder over the next 16 hours).
Direct thermal injury predominantly affects upper
airway structures. Injury to the lower airway typically
occurs due to inhalation of toxic gases and particulate
matter.
Wound care principles for minor wounds can be
applied to patients with minor burns.
Silver sulfadiazine cream (Silvadene) is most
commonly used with closed burn dressings for the
management of superficial partial-thickness burns. It
should be avoided on the face, in infants, in late-term
pregnancy, or in those with sulfonamide allergy or
G6PD deficiency.
Young children have an increased body surface area
to weight ratio compared with adults, therefore
requiring greater fluid than determined with
the use of standard weight-based resuscitation
formulas.
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